Medical Consent

First Name *

Last Name *

Email *

Phone *

1. Consent to Medical Treatment *

I am voluntarily requesting medical evaluation and treatment.

The provider may recommend tests, prescriptions, procedures, or other care.

I can ask questions, decline, or withdraw consent any time.

2. Telehealth Consent *

Telehealth may involve video, audio, messaging, or images.

It has benefits (faster access) and risks (technical or privacy issues).

3. Privacy & Confidentiality *

My information is protected under HIPAA or applicable laws.

Reasonable measures will protect my data.

4. Accuracy of Information *

I confirm all information I provide is accurate.

I will notify the provider about any changes in my health.

5. Acknowledgment *

I have read and understand the information above.

I consent to medical and telehealth services.

I am at least 18 years old or legally authorized to consent.

Medical Consent Accepted *

I have read and agree to the Medical Consent to Treatment.